Gavin Leslie

Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit

Objectives: To determine the incidence and nature of adverse events and delay to patient transfer from emergency department to intensive care unit (ICU) in a metropolitan tertiary hospital. Method: A 6-month prospective observational study in conjunction with a retrospective chart audit on all emergency department patients admitted to ICU, including those admitted via theatre or after a computed tomography scan. Results: Equipment problems was the most common adverse event occurring in 9% of patient transfers (n = 290). Hypothermia events occurred in 7% of transfers, cardiovascular events in 6% of patient transfers, delays to transfer >20 min occurred in 38% of the prospectively audited cases, with 14% waiting >1 h. One patient was found to have an incorrect patient identification band during a preoperative check. Conclusions: This study generally reported lower rates of adverse events than noted in previous studies involving critically ill transfers. The most significant finding was the application of an incorrect patient identification band and has prompted a review of practice. The establishment of benchmark indicators for adverse events and delays in transfer will be useful for future audits.

The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears

A cluster randomised controlled trial was conducted to evaluate the effectiveness of a twice‐daily moisturising regimen as compared to ‘usual’ skin care for reducing skin tear incidence. Aged care residents from 14 Western Australian facilities (980 beds) were invited to participate. The facilities were sorted into pairs and matched in terms of bed numbers and whether they provided high or low care. One facility from each matched pair was randomised to the intervention group. Consenting residents in an intervention facility received a twice‐daily application of a commercially available, standardised pH neutral, perfume‐free moisturiser on their extremities. Residents in the control facilities received ad hoc or no standardised skin‐moisturising regimen. Participant numbers were sufficient to detect a 5% difference in incidence rate between the two groups with 80% power and a significance level of P = 0·05, and the inter‐cluster correlation coefficient was 0·034. Data were collected over 6 months. A total of 1396 skin tears on 424 residents were recorded during the study. In the intervention group, the average monthly incidence rate was 5·76 per 1000 occupied bed days as compared to 10·57 in the control group. The application of moisturiser twice daily reduced the incidence of skin tears by almost 50% in residents living in aged care facilities.

Beyond the walls: A review of ICU clinics and their impact on patient outcomes after leaving hospital

INTRODUCTION Patients often experience physical disability, neurocognitive and/or psychological impairment after surviving ICU. The burden arising from critical illness on patients, their families and health services may be substantial. Follow-up of these patients is important and ICU clinics have been introduced for this purpose. AIM The aim of this review was to consider current research and reports from the literature about ICU follow-up clinics and their impact on patient outcomes for those who survived hospital after suffering critical illness. METHOD The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies were included if they described the setting up and conduct of the ICU follow-up clinic that required a visit to the clinic. RESULTS Seven studies met the inclusion criteria, six of which were from the UK. The ICU follow-up clinics were predominantly nurse-led. There was no consensus on patient selection criteria for clinic attendance or method of follow-up. Clinic services were most often offered to patients who stayed in ICU three or more days. Attendance rates varied and were not reported for three studies. Attendance appeared to be influenced by the severity of illness. Cancellation and non-attendance rates were high for those studies reporting these data. Patients who did not live within the vicinity of the hospital were often excluded. Information about the sequelae of critical illness was provided and attendees were happy to discuss their experiences at the clinic. However, other important outcomes were not reported. CONCLUSION Appropriate follow-up for survivors of intensive care and their family is important. However, evidence is limited on the benefit of ICU clinics for patients recovering from critical illness. Further research is needed to examine models that best meet patient needs after critical care.

Using a web-based survey tool to undertake a Delphi study: Application for nurse education research

BACKGROUND The Internet is increasingly being used as a data collection medium to access research participants. This paper reports on the experience and value of using web-survey software to conduct an eDelphi study to develop Australian critical care course graduate practice standards. METHODS The eDelphi technique used involved the iterative process of administering three rounds of surveys to a national expert panel. The survey was developed online using SurveyMonkey. Panel members responded to statements using one rating scale for round one and two scales for rounds two and three. Text boxes for panel comments were provided. COLLECTING DATA AND PROVIDING FEEDBACK For each round, the SurveyMonkeys email tool was used to distribute an individualized email invitation containing the survey web link. The distribution of panel responses, individual responses and a summary of comments were emailed to panel members. Stacked bar charts representing the distribution of responses were generated using the SurveyMonkey software. Panel response rates remained greater than 85% over all rounds. DISCUSSION An online survey provided numerous advantages over traditional survey approaches including high quality data collection, ease and speed of survey administration, direct communication with the panel and rapid collation of feedback allowing data collection to be undertaken in 12 weeks. Only minor challenges were experienced using the technology. Ethical issues, specific to using the Internet to conduct research and external hosting of web-based software, lacked formal guidance. CONCLUSIONS High response rates and an increased level of data quality were achieved in this study using web-survey software and the process was efficient and user-friendly. However, when considering online survey software, it is important to match the research design with the computer capabilities of participants and recognize that ethical review guidelines and processes have not yet kept pace with online research practices.

Decrease in proven ventriculitis by reducing the frequency of cerebrospinal fluid sampling from extraventricular drains

OBJECT Ventriculitis associated with extraventricular drains (EVD) increases rates of morbidity and mortality as well as costs. Surveillance samples of CSF are taken routinely from EVD, but there is no consensus on the optimum frequency of sampling. The goal of this study was to assess whether the incidence of ventriculitis changed when CSF sampling frequency was reduced once every 3 days. METHODS After receiving institutional ethics committee approval for their project, the authors compared a prospective sample of EVD-treated patients (admitted 2008-2009) and a historical comparison group (admitted 2005-2007) at two tertiary hospital ICUs. A broad definition of ventriculitis included suspected ventriculitis (that is, treated with antibiotics for ventriculitis) and proven ventriculitis (positive CSF culture). Adult ICU patients with no preexisting neurological infection were enrolled in the study. After staff was provided with an education package, sampling of CSF was changed from daily to once every 3 days. All other management of the EVD remained unchanged. More frequent sampling was permitted if clinically indicated during the third daily sampling phase. RESULTS Two hundred seven patients were recruited during the daily sampling phase and 176 patients when sampling was reduced to once every 3 days. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was lower for the daily sampling group than for the every-3rd-day group (18.6 vs 20.3, respectively; p < 0.01), but there was no difference in mean age (47 and 45 years, respectively; p = 0.14), male or female sex (61% and 59%, respectively; p = 0.68), or median EVD duration in the ICU (4.9 and 5.8 days, respectively; p = 0.14). Most patients were admitted with subarachnoid hemorrhage (42% in the daily group and 33% in the every-3rd-day group) or traumatic head injuries (29% and 36%, respectively). The incidence of ventriculitis decreased from 17% to 11% overall and for proven ventriculitis from 10% to 3% once sampling frequency was reduced. Sampling of CSF once every 3 days was independently associated with ventriculitis (OR 0.44, 95% CI 0.22-0.88, p = 0.02). CONCLUSIONS Reducing the frequency of CSF sampling to once every 3 days was associated with a significant decrease in the incidence of ventriculitis. The authors suggest that CSF sampling should therefore be performed once every 3 days in the absence of clinical indicators of ventriculitis. Reducing frequency of CSF sampling from EVDs decreased proven ventriculitis.

Proximally delivered dilute heparin does not improve circuit life in continuous venovenous haemodiafiltration

ObjectiveTo assess the effect on circuit life in continuous venovenous haemodiafiltration (CVVHD) by manipulating heparin dilution and point of administration.DesignRepeated crossover design. Cases were randomised for first circuit and heparin dilution, after which crossovers occurred until treatment was stopped.SettingA 24-bed combined general and surgical intensive care unit admitting 1900 patients a year. On average, 54 cases a year receive CVVHD.Patients26 critically ill adult patients requiring CVVHD were enrolled, 18 of whom used at least one standard circuit and one modified circuit.InterventionsTwo circuit configurations and heparin dilutions were compared. In combination A, standard CVVHD blood lines and heparin concentration (100 units/ml) were used. In combination B, heparin was delivered in a more dilute volume (10 units/ml) via a modified circuit design with an administration port immediately adjacent to the venous access.Measurements and results18 randomised crossovers of circuits A and B occurred. Mean/median circuit life for the standard heparin/circuit combination A was 20.1/17.5 (SD 14.6) and for the modified combination B 21.4/15.4 (SD 19.2). There was no significant difference between circuits (pairedt-test,p=0.8175). To identify other factors which could have influenced circuit life (platelet count, heparin dose and pre- and post-filter activated partial thromboplastin time, APTT) all circuits terminated for the reasons identified (n=105) were analysed using linear modelling. Survival analysis was used to determine the survival function of the circuit. Pre-heparin APTT was the only factor associated with an increase in filter life (p=0.0325). The hazard rate for filter failure was 0.049/h (95% confidence interval 0.04 to 0.06), the range of time until filters failed was 1.8 to 78.5 h.ConclusionsProximally administered dilute heparin is not associated with a significant increase in circuit life.

Determining risk factors for surgical wound dehiscence: a literature review

Postoperative wound healing plays a significant role in facilitating a patients recovery and rehabilitation. Surgical wound dehiscence (SWD) impacts on mortality and morbidity rates and significantly contributes to prolonged hospital stays and associated psychosocial stressors on individuals and their families. A narrative review of SWD was undertaken on English‐only studies between 1945 and 2012 using three electronic databases Ovid CINHAL, Ovid Medline and Pubmed. The aim of this review was to identify predisposing factors for SWD and assessment tools to assist in the identification of at‐risk patients. Key findings from the included 15 papers out of a search of 1045 revealed the most common risk factors associated with SWD including obesity and wound infection, particularly in the case of abdominal surgery. There is limited reporting of variables associated with SWD across other surgical domains and a lack of risk assessment tools. Furthermore, there was a lack of clarity in the definition of SWD in the literature. This review provides an overview of the available research and provides a basis for more rigorous analysis of factors that contribute to SWD.

A qualitative exploration of nurse's perception of Critical Outreach Service: a before and after study.

BACKGROUND Critical Care Outreach Services (CCOS) have been reported to streamline the transfer of patients from the intensive care unit (ICU) to the wards and provide a follow-up service supporting ward staff to provide optimum care for patients discharged from ICU. PURPOSE The aim of this study was to explore the perceptions of nursing staff before and after the introduction of a CCOS at three adult teaching hospitals in Perth, Western Australia. METHODS Exploratory focus groups were conducted with registered nurses (RNs) at each of the participating hospitals prior to and 6 months after the introduction of a CCOS. Framework analysis was used to analyse the transcribed data using a thematic approach with themes developed from the narratives of the participants. RESULTS Inexperienced RNs in particular voiced positive comments about the CCOS. The role was seen as a senior nurse who was an additional resource for less experienced staff as they educated them on complex procedures that were not common on the general wards. The RNs reported that apprehensions about the role that they had pre-implementation were not borne out in practice and that they believed that the CCOS had positive effects on patient outcomes. CONCLUSION The CCOS improved communication processes between members of the multidisciplinary team and units within the hospital, which subsequently enhanced the ward transition process for critically ill patients and ward nursing staff.

Clinical Effectiveness of a Critical Care Nursing Outreach Service in Facilitating Discharge From the Intensive Care Unit

BACKGROUND Improved discharge planning and extension of care to the general care unit for patients transferring from intensive care may prevent readmission to the intensive care unit and prolonged hospital stays. Morbidity, mortality, and costs increase in readmitted intensive care patients. OBJECTIVES To evaluate the clinical effectiveness of a critical care nursing outreach service in facilitating discharge from the intensive care unit and providing follow-up in general care areas. METHODS A before-and-after study design (with historical controls and a 6-month prospective intervention) was used to ascertain differences in clinical outcomes, length of stay, and cost/benefit. Patients admitted to intensive care units in 3 adult teaching hospitals were recruited. The service centered on follow-up visits by specialist intensive care nurses who reviewed and assessed patients who were to be or had been discharged to general care areas from the intensive care unit. Those nurses also provided education and clinical support to staff in general care areas. RESULTS In total, 1435 patients were discharged during the 6-month prospective period. Length of stay from the time of admission to the intensive care unit to hospital discharge (P = .85), readmissions during the same hospital admission (5.6% vs 5.4%, P = .83), and hospital survival (P = .80) did not differ from before to after the intervention. CONCLUSIONS Although other studies have shown beneficial outcomes in Australia and the United Kingdom, we found no improvement in length of stay after admission to the intensive care unit, readmission rate, or hospital mortality after a critical care nursing outreach service was implemented.

Living Beyond the Unanticipated Sudden death of a partner: A phenomenological study

This research project explored grief and its impact upon men and women who have experienced the sudden and unanticipated death of his or her partner. It included what grief meant to them, how it was manifested in his or her everyday lives and how his or her partners death had impacted upon his or her relationship with themselves, with others and the world. A Husserlian phenomenological approach was used to explore the experiences of the ten women and five men whose partner had died up to five years prior to being interviewed. The need for the surviving partner to continue to participate in everyday life placed great strain upon the internal resources of the surviving partner. The surviving partner needed to reinvent him or herself, in an attempt to become independent and regain functionality, whilst dealing with the sadness and loss that they had experienced. The surviving partner discovered that a new life order emerged that included hope, optimism, planning for the future and perhaps the prospect of a new relationship. The death of a partner left the surviving partner with a loss that would always be a part of them, with the memories of his or her relationship being maintained within them that will never be replaced by somebody else. The results of this research project reinforce the need for ongoing education of the community in grief and bereavement issues in order to increase the awareness of the support needs of the bereaved person. The length of time and amount of energy required to incorporate the experience into the survivors life, is greatly underestimated by the community, and perhaps by some of the health and caring professionals. Colonial and hospital based bereavement support services need to be established and be proactive using outreach programs, actively offering the suddenly bereaved partner and family support and information.